Why e-Prescribe and the Future of Transforming Data Into Information

■■ Why e-Prescribe and the Future of Transforming Data Into Information Political interest is probably poor motivation for information technology (IT) solutions to reduce medical errors, protect patient safety, improve clinical decisions at the point of care, and reduce the administrative burden for clinicians. Physicians in the United Kingdom are disturbed, concerned, and even appalled at the next generation of IT solutions that are being demonstrated for universal application in the National Health Service. Attendees at the government sessions to introduce the new software to physicians described “IT nightmares” and the likely outcome of making routine functions such as patients booking appointments with general practitioners less efficient while robbing resources from creating additional capacity to deliver health care services. The gap between expectations and reality is large nearly everywhere one looks in health care. While there are success stories, more often, the truth is that success stories are limited to distinct subsets or compartments of the health care system; use of the IT solution is voluntary by clinicians, thereby undermining the value of digital information because it is not complete; the IT system is plagued with error;or a backlash occurs among clinicians who find the new IT system burdensome rather than helpful. The solution to IT overpromises is lower expectations for IT proposals to meet the need for safety, quality, and administrative efficiency in health care. While IT may offer tools to achieve minimum targets for patient safety, experts such as Don Berwick and Brent James argue that more fundamental changes are necessary in philosophy and culture to protect patient safety. Brent James teaches a culture of patient safety with accountability that extends to the board of directors of the corporation or health system enterprise. Don Berwick and coauthors recently addressed the notion that protecting patient safety in health care is as simple as adapting the success stories from civil aviation, nuclear power, and other industries. They argue for a framework to guide quality improvement that acknowledges 5 systemic barriers to safe patient care and 3 problems unique to health care. The systemic barriers arise from the discretion permitted for workers, worker autonomy, a craftsmanship mindset (that needs to transition to a mindset of equivalent actors), insufficient system-level (senior leadership) arbitration to optimize safety strategies, and the need for simplification. The 3 problems unique to health care are: (1) a wide range of risk among medical specialties, (2) difficulty in defining medical error, and (3) various structural constraints (such as public demand, teaching role, and chronic shortage of staff). For many years, Brent James and others have championed the notion of making it easy to do it right—addressing systems and processes of care, regardless of electronic tools, including the insertion of standardized orders such as aspirin and beta-blockers upon hospital discharge following an acute myocardial infarction. However, it seems reasonable to ask why it is easy to have a customer profile at the nationwide pizza chain but necessary for you to complete a patient profile and medical history at every point in the health care journey from the physician office to the hospital laboratory to the medical imaging center, etc. Clearly, there is a need not only for patient safety but also for favorable service outcomes of care and for administrative efficiency to embrace electronic capture and transfer of information. Stories abound of difficulty in integrating data across different software systems, even as basic as the integration of e-prescribing with medication administration processes. Electronic prescribing, or e-prescribing, also known as computerized physician order entry (CPOE), has moved from the health care agenda to the political agenda. General Motors Corp., IBM, AT&T, General Electric, Boeing, and 91 other employers collaborated in 2001 to form the Leapfrog Group to, as its name implies, leapfrog over the present (slow) pace of quality improvement in health care. The Leapfrog Group in 2001 defined 3 basic ways to improve safety and quality of health care for at least the hospital component of the health care system, including the recommendation that managed care organizations contract with only those hospitals that have implemented a computerized order entry system by 2004. In 2005, former Speaker of the House of Representatives Newt Gingrich sought to propel his vision of a digital health system with the slogan “paper kills,” meaning that clinical and other patient information on paper can harm the patient in the health care system because the information is not available at the point of care. Surely, e-prescribing represents an undisputed opportunity to reduce medical errors, improve clinical outcomes, and increase efficiency. More expectation for the value of CPOE was added in April 2005 when the Big Three U.S. automakers asked 17,000 physicians to switch to e-prescribing after General Motors announced (again) that it spends more money on health care than for steel. Two articles in JMCP provide differing perspectives on the value of e-prescribing. In this issue, Ross et al. found that neither formulary compliance nor rates of generic drug dispensing were different for predominant e-prescribers compared with traditional prescribers. Approximately 1 in 5 pharmacy claims were for nonformulary drugs for both types of prescribers, and the generic drug dispensing ratio was approximately 37% (in 2001-2002) for both groups. This study by Ross et al. would appear to be a withering endorsement for e-prescribing, but perhaps not. First, Ross et al. could not assure that the clinicians identified as e-prescribers used e-prescribing devices 100% of the time, 90% of the time, or even half of the time; hence, the term “predominant e-prescribers” in their article. This means that a portion of the pharmacy claims labeled as e-prescriptions by the authors were, in fact, not e-prescriptions, potentially diluting a higher ratio of either formulary or generic drug prescribing


II Why e-Prescribe and the Future of Transforming Data Into Information
Political interest is probably poor motivation for information technology (IT) solutions to reduce medical errors, protect patient safety, improve clinical decisions at the point of care, and reduce the administrative burden for clinicians. Physicians in the United Kingdom are disturbed, concerned, and even appalled at the next generation of IT solutions that are being demonstrated for universal application in the National Health Service. 1 Attendees at the government sessions to introduce the new software to physicians described "IT nightmares" and the likely outcome of making routine functions such as patients booking appointments with general practitioners less efficient while robbing resources from creating additional capacity to deliver health care services. 2 The gap between expectations and reality is large nearly everywhere one looks in health care. While there are success stories, more often, the truth is that success stories are limited to distinct subsets or compartments of the health care system; use of the IT solution is voluntary by clinicians, thereby undermining the value of digital information because it is not complete; the IT system is plagued with error 3 ;or a backlash occurs among clinicians who find the new IT system burdensome rather than helpful. 4 The solution to IT overpromises is lower expectations for IT proposals to meet the need for safety, quality, and administrative efficiency in health care.
While IT may offer tools to achieve minimum targets for patient safety, experts such as Don Berwick and Brent James argue that more fundamental changes are necessary in philosophy and culture to protect patient safety. Brent James teaches a culture of patient safety with accountability that extends to the board of directors of the corporation or health system enterprise. 5 Don Berwick and coauthors recently addressed the notion that protecting patient safety in health care is as simple as adapting the success stories from civil aviation, nuclear power, and other industries. They argue for a framework to guide quality improvement that acknowledges 5 systemic barriers to safe patient care and 3 problems unique to health care. The systemic barriers arise from the discretion permitted for workers, worker autonomy, a craftsmanship mindset (that needs to transition to a mindset of equivalent actors), insufficient system-level (senior leadership) arbitration to optimize safety strategies, and the need for simplification. 6 The 3 problems unique to health care are: (1) a wide range of risk among medical specialties, (2) difficulty in defining medical error, and (3) various structural constraints (such as public demand, teaching role, and chronic shortage of staff). For many years, Brent James and others have championed the notion of making it easy to do it right-addressing systems and processes of care, regardless of electronic tools, including the insertion of standardized orders such as aspirin and beta-blockers upon hospital discharge following an acute myocardial infarction. 7 However, it seems reasonable to ask why it is easy to have a customer profile at the nationwide pizza chain but necessary for you to complete a patient profile and medical history at every point in the health care journey from the physician office to the hospital laboratory to the medical imaging center, etc. Clearly, there is a need not only for patient safety but also for favorable service outcomes of care and for administrative efficiency to embrace electronic capture and transfer of information. Stories abound of difficulty in integrating data across different software systems, even as basic as the integration of e-prescribing with medication administration processes. 8 Electronic prescribing, or e-prescribing, also known as computerized physician order entry (CPOE), has moved from the health care agenda to the political agenda. General Motors Corp., IBM, AT&T, General Electric, Boeing, and 91 other employers collaborated in 2001 to form the Leapfrog Group to, as its name implies, leapfrog over the present (slow) pace of quality improvement in health care. The Leapfrog Group in 2001 defined 3 basic ways to improve safety and quality of health care for at least the hospital component of the health care system, including the recommendation that managed care organizations contract with only those hospitals that have implemented a computerized order entry system by 2004. 9 In 2005, former Speaker of the House of Representatives Newt Gingrich sought to propel his vision of a digital health system with the slogan "paper kills," meaning that clinical and other patient information on paper can harm the patient in the health care system because the information is not available at the point of care. 10 Surely, e-prescribing represents an undisputed opportunity to reduce medical errors, improve clinical outcomes, and increase efficiency. More expectation for the value of CPOE was added in April 2005 when the Big Three U.S. automakers asked 17,000 physicians to switch to e-prescribing after General Motors announced (again) that it spends more money on health care than for steel. 11 Two articles in JMCP provide differing perspectives on the value of e-prescribing. In this issue, Ross et al. found that neither formulary compliance nor rates of generic drug dispensing were different for predominant e-prescribers compared with traditional prescribers. 12 Approximately 1 in 5 pharmacy claims were for nonformulary drugs for both types of prescribers, and the generic drug dispensing ratio was approximately 37% (in 2001-2002) for both groups. This study by Ross et al. would appear to be a withering endorsement for e-prescribing, but perhaps not.
First, Ross et al. could not assure that the clinicians identified as e-prescribers used e-prescribing devices 100% of the time, 90% of the time, or even half of the time; hence, the term "predominant e-prescribers" in their article. This means that a portion of the pharmacy claims labeled as e-prescriptions by the authors were, in fact, not e-prescriptions, potentially diluting a higher ratio of either formulary or generic drug prescribing among the truly predominant e-prescribers. Second, the findings by Ross et al. are restricted to 2 intermediate outcome measures: the ratios of formulary prescription claims and generic drugs to total pharmacy claims. Possible administrative efficiency in the form of fewer calls between prescribers and pharmacies was not measured quantitatively but noted as a qualitative finding from a survey of some prescribers. There is also the administrative efficiency for the pharmacy in the entry of keystrokes by prescribers rather than pharmacy staff for prescription orders. But, others have observed from the current environment of e-prescribing that small independent pharmacies are slow to upgrade their pharmacy management systems to accept e-prescriptions because of large fees charged by software vendors; large chain pharmacies embrace e-prescribing at the corporate level, but local store support is low and there is inadequate training of pharmacy staff. 13 Physician resistance to change, system cost, and inadequate planning to incorporate e-prescribing into the existing care process have been blamed for failures in introducing e-prescribing in health systems. 4 The Centers for Medicare and Medicaid Services (CMS) acknowledged the receipt of about 100 comments in response to the CMS proposal in early February 2005 for e-prescribing standards to take effect prior to the start of the Medicare Part D benefit on January 1, 2006. William Jesse, CEO of the Medical Group Management Association (MGMA), wrote in his letter to CMS Administrator Mark McClellan that the MGMA contends that the benefits of e-prescribing compared with its costs are "simply not evident." The letter also called for CMS to "establish a quantifiable return on investment through survey research and a comprehensive cost-benefit analysis for all sizes of physician practices." 14 The American Medical Association has been critical of the political agenda to mandate e-prescribing by physicians. 15 Modern Healthcare's 14th annual survey of information systems needs conducted in January 2004 found that 24% of surveyed organizations had a CPOE system either in operation or implementation, about the same number as the year before, in January 2003. Unlike 2003, however, in which 40% of those without a CPOE system in operation or implementation reported that they planned to add a CPOE system within the next year, in January 2004, only 26% expected to do so in the next year. 16 Data from the National Health Care Survey, Centers for Disease Control and Prevention, suggest a less pronounced dissemination of information technology for office-based physicians. In 2003, only 7.9% of office-based physicians used CPOE, 17.2% had electronic medical records (EMR), and 73.2% used electronic billing for their-party claims. 17 The CDC data support the Modern Healthcare survey data in the more widespread use of information technology in hospitals with 31% of emergency departments and 29% of hospital outpatient centers reporting use of EMR.
Amid the pushback from some physicians and the apparent waning interest of health systems in e-prescribing, there is evidence of improved cost outcomes and efficiency in the use of e-prescribing. In the May 2005 issue of JMCP, McMullin et al. found that e-prescribing that included a clinical decision support system (CDSS) was associated with significant drug cost savings and reduction in the proportion of high-cost drugs in 8 therapeutic categories that were the target of CDSS messages to prescribers. 18 Over 12 months of follow-up, the average cost per prescription was reduced by $2.57 (5.3%), and PMPM drug cost was reduced by $1.07 (5.4%) in the e-prescribing group compared with the control group. Average drug cost savings of $863 to $873 per prescriber per month overwhelmed the administrative cost of the e-prescribing system. Targeted highcost drugs in the 8 therapeutic categories were 17.5% lower in the intervention group (35.8%) compared with the control group (43.4%, P = 0.03).
So, an e-prescribing system with CDSS can influence prescribing and produce drug cost savings. While important to health systems at risk for pharmacy benefit costs, another factor seems to guarantee that e-prescribing will increase in frequency and soon overtake traditional prescribing, perhaps due to factors other than evidence that e-prescribing can be used to reduce direct drug costs. In the last year, Blackberry and other wireless communication devices have been breaking down barriers of resistance to change. The ubiquitous and loweffort features of this technology will transfer to clinician prescribing, and rather than resisting e-prescribing, clinicians will be demanding it. Yet, it will remain necessary to spend money on new and upgraded system software to integrate e-prescribing with the electronic medical record to overcome electronic silos of data that reside in pharmacies, at pharmacy benefit managers, or in data warehouses and are not available to clinicians at the point of care.
What will shorten the timeline between the reality of today and the inevitability of tomorrow is studious examination of the work of pioneers in adapting and implementing IT solutions in health care settings. Among the many sources of this information is a compilation by GroupPOE, created in October 2002, entitled "Landmines and Pitfalls of Computerized Prescriber Order Entry." 19 While nearly 3 years old, the recommendations and lessons contained in this document are still relevant and useful today.